Information Regarding Immunizations

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1 Information Regarding Immunizations Dear Staff Member / Volunteer The state of Massachusetts require our staff members and volunteers aged 17 and under to have and provide evidence of the following immunizations: Tdap Polio Hepatitis B MMR Varicella 1 dose; and history of DTaP primary series or age appropriate catch-up vaccination. Tdap given at 7 years may be counted, but a dose at age is recommended if Tdap was given earlier as part of a catch-up schedule. Td should be given if it has been 10 years since Tdap. 4 doses; 4 th dose must be given on or after the 4 th birthday and 6 months after the previous dose, or a 5 th dose is required. 3 doses are acceptable if the 3 rd dose is given on or after the 4 th birthday and 6 months after the previous dose. 3 doses; laboratory evidence of immunity acceptable 2 doses; first dose must be given on or after the 1 st birthday and the 2 nd dose must be given 28 days after dose 1; laboratory evidence of immunity acceptable 2 doses; first dose must be given on or after the 1 st birthday and 2 nd dose must be given 28 days after dose 1; a reliable history of chickenpox* or laboratory evidence of immunity acceptable The deadline for submitting proof of immunizations is 10 days before your first chosen session start date. 1. If you are returning to camp, please contact the camp office to see if the required information is currently held on our system from previous years. 2. To prove immunization, a licensed healthcare provider can complete the Immunization Record Form enclosed, or you can obtain a copy of your vaccination record from your health care provider. There are three options for submitting this information: A. Provide a copy of your records to our online system: by scanning and uploading the forms B. Fax to (978) C. 3. Upon receipt, our nurses will be in touch to confirm receipt and follow up on any queries. If you have any questions do not hesitate to contact the office at or 1 of 5

2 Exemptions The following exemptions may be allowed: 1. Religious Exceptions If you have religious objections to physical examinations or immunizations, you may submit a written statement, signed by yourself, to the effect that you are in good health and stating the reason for such objections. 2. Immunization Contraindicated Any immunization specified shall not be required if the Health History Form includes a certification by a physician that he or she has examined you and that in the physician's opinion the physical condition of yourself is such that your health would be endangered by such immunization. Whilst we appreciate these requirements are time consuming and, lets face it, pretty inconvenient, they are a legal requirement and ensure we run a compliant, safe and well regulated summer camp. I thank you for your cooperations with this and look forward to seeing you soon! Blessings, Breeze Everitt Director of Summer Camping 2 of 5

3 Part 1 Staff / Volunteer Information Immunizations Record Form Your Name Date of Birth Sex: Parts 2 to 7 are to be completed by a Healthcare provider. All dates must include MONTH, DAY and YEAR. Part 2 Measles, Mumps, Rubella Staff / Volunteers born on or before January 1, 1957 will not have to provide immunity for MMR MMR #1 Date of Vaccine MMR #2 Date of Vaccine (must be given on or after 12 months of age/first birthday) OR (must be given at least 28 days after MMR #1) If individual vaccines were received for Measles, Mumps, and Rubella, please complete the following: Measles (Rubeola) Vaccine Date of Vaccine #1 Rubella (German Measles) Vaccine Date of Vaccine #1 Mumps Vaccine Date of Vaccine #1 If proof of vaccine cannot be provided, you must obtain a blood titer to confirm immunity of all of the above. 3 of 5

4 Part 3 Tetanus/Diphtheria/Pertussis (DPT,DTP,DT,DTap,Td or Tdap) Date of Vaccine # 1 Date of Vaccine # 2 Date of Vaccine # 3 Date of Vaccine # 4 Part 4 - Varicella (Chicken Pox) Date of Vaccine # 1 Date of Vaccine # 2 Or Applicant has previously had Chicken Pox Part 5 - Polio Date of dose # 1 Date of dose # 2 Date of dose # 3 Date of dose # 4 Part 6 - Hepatitis B Date of dose # 1 Date of dose # 2 Date of dose # 3 4 of 5

5 Part 7 - Healthcare Provider Certification Providers Signature Providers Printed Name Address Phone Number 5 of 5

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